Note: This section was used as a Patient Take-Home Guide.
It may be freely copied, provided proper credit is given.
The exercises you will be doing are popularly called the "Kegel Exercises" because they were first
developed by a gynecologist named Arnold Kegel of California in the 1940s. He devised them to help
women who were suffering from "urinary stress incontinence" --- a broad term covering any involuntary
loss or leakage from the bladder during physical exertion, such as coughing, lifting, bending or jumping.
Kegel found that by learning to tighten or contract the "pubococcygeus" (or "PC") muscle women could
learn to control the leakage of urine --- without the need for surgery. After doing these exercises faithfully
for several weeks, all women developed stronger muscles and almost all reported that they no longer had
experienced incontinence. Now, thanks to the new science of computerized electronic biofeedback, it is
possible to learn to do these Kegel exercises even faster and more effectively than was possible in Kegel's
day. As a result, many persons have been able to avoid surgery or repeat surgery and remain continent.
Originally Dr. Kegel treated only patients with "Stress" Incontinence. More recently, it has been discovered
that the other common forms of urinary incontinence, namely "Urge Incontinence" and "Uninhibited (or
Hyper-reflexive) Bladder" respond equally well to biofeedback training. Today the biofeedback method is
used with any urinary incontinence that is not the result of an abnormal growth (tumor) or an infection.
It is impossible to predict how long it will take to totally restore urinary control. A number of factors are
involved, including (1) the length of time that the problem has existed, (2) the person's over-all physical
condition, (3) the presence of scar tissue or nerve damage from previous surgeries (4) the actual amount
of muscle atrophy or weakness, and (5) the use of a home-trainer for daily practice.
But by far the most important factor is the actual amount of time that the patient is willing to spend in daily
at-home practice. We have noticed, for example, that older, retired patients tend to get better faster than
patients who are younger and still working. Although that at first seems paradoxical, the explanation is
perfectly clear: the retired patients tend to spend more time--up to twice as much time-- practicing these
exercises. So they get better faster.
One of the major advantages of biofeedback-assisted exercises such as these is that the biofeedback
monitoring equipment is able to detect increases in pelvic muscle strength at a level far below that which
would result in an improvement in symptoms. In other words, the biofeedback approach can show when you
are getting better, even if you are not better enough to have any noticeable change in your incontinence
symptoms. During the first week or two or three, you will discover that your muscles are getting stronger,
even though you are still having urinary accidents (or urgency) one or more times a day. Without the
objective data of biofeedback, you would probably have become discouraged and would have given up, just
before your muscles were strong enough to control your urinary leakage.
The EMG Perineometer sensor is capable of providing you with extremely accurate "feedback" about the
condition and activity of your pelvic muscles, which are otherwise not very easy to observe. It operates on
the principle that when human muscles are activated by signals from the brain, they produce an extremely
tiny electrical potential which is detected by the sensor, processed by the biofeedback instrument, and
translated into visual and auditory signals which let you know how your internal muscles are responding to
your mental instructions.
With a little practice, you will learn to become more aware of natural internal sensations which correspond
to the visual and auditory feedback provided by the EMG biofeedback instrument. As your own senses
become keener, you will gradually come to trust them more, and you will need the external "biofeedback"
less and less. Eventually, you won't need the instruments at all. Your practice of Kegel exercises will
become an automatic reflex, occurring many times throughout the day. When that happens, your PC muscle
will become stronger and healthier.
In addition to this pamphlet of general instructions, your therapist will also provide you with specific instructions about the EMG instrument which you have purchased or rented. That will explain how to use the various switches and knobs and how to interpret the lights, meters, or sound feedback signals that may be available. If there is anything you do not understand, please ask your therapist for more details. You will get the maximum benefit if you understand how the instrument works.
You should also receive a daily exercise log with specific goals for each day, and a place to record your
daily performance and other comments. It is important to keep a record of your progress, because
(especially in the first two weeks) it is easy to become discouraged. To begin your exercise program, you
should plan to set aside two exercise periods during the day Ð preferably once in the morning and another
in the afternoon or evening. Pick a time when you can be assured of no interruptions. This allocation of
time is especially important during the first two to four weeks. As your muscles get better you will be able
to cut back on the formal exercise time and begin doing more "spontaneous" exercise throughout the day.
You will probably find it most convenient to do your exercises lying on your bed, but they can also be done
sitting in a comfortable chair. (Dr. Kegel recommended doing the morning exercises immediately upon
awakening, before arising from bed, since (1) your muscles would be most relaxed and (2) they would yet
not be subjected to the strain of the weight of the internal organs.)
Inserting the Vaginal Sensor
The first step in inserting the vaginal sensor is NOT to insert it! Just take a few moments to lie still and relax, and think of what you are about to do. Your ability to learn pelvic muscle awareness will be greatly enhanced if your mind is quiet and free from distracting thoughts. Also, you need to relax your muscles to make insertion of the sensor easier. If the labia around the vaginal entrance is dry, you should first moisten the delicate skin with saliva, or a small amount of a water-soluble lubricant such as K-Y Jelly. (Never use vasoline in that part of the body; it clogs the pores.)
When you are relaxed and the entrance is moist, slowly insert the sensor (with its cable already attached)
into the vagina just as you would a tampon. (The larger end with its connecting cable should always remain
outside the vaginal entrance.) If you have trouble inserting it, just relax, and try again in a minute.
Warning:
If irritation or inflamation of the vaginal skin develops, discontinue use of the sensor and contact your physician or therapist for
professional advice. Always be certain that all traces of soap, detergent, and sterilizing solution have been rinsed from the sensor
before using it.
If you have not already done so, now connect the free end of the cable to your EMG biofeedback instrument. Then turn it on, and notice the indicated level of relaxation. Do a couple of quick "flicks" to assure yourself that the instrument is registering properly, and then PAUSE. If you are not showing a "relaxed" reading (the exact indication varies from one instrument to another; follow the instructions and your therapist's advice here) take some time to try to relax before beginning the exercises. Sometimes it is easier to relax if you first try to contract your muscles and then just do "the opposite" to relax.
Exercise Sequence
The normal sequence and number of contractions which should constitute your own personal exercise
program will be suggested by your therapist. Normally, you should expect to increase the amount of
exercise you do each week until your incontinence is under control. Then you will begin to taper off to a
"maintenance level" of exercise that you will ultimately continue (without the need for the biofeedback
equipment) for the rest of your life.
You may also develop your own exercise program, based on the suggestions in Chapter 4 of The G Spot, or Chapter 2 in Elizabeth Noble's book Essential Exercises for the Child-Bearing Year, or Lonnie Barbach's For Yourself.
Flicks or Holds, or Both?
In previous editions of these instructions we recommended that patients practice both "flicks" (short
contractions) and "holds" (10-second contractions), because most therapists have historically
recommended that. Now, based on recent research, we no longer recommend that anyone practice "flicks".
The reason is that scientific research has shown that the ability to make quick contractions, however
strong, does not correlate with urinary control. (If the toilet is 20 seconds away, and you can only hold the
sphincter for 3 seconds, it stands to reason that you'll start to leak urine about 17 seconds away from the
toilet!) Theoretically, short contractions build up the "phasic" component of the muscle, which is not really
helpful. For urinary control, we need to increase the number of "tonic" muscle fibers. The only way to do
that is to practice longer contractions Ð commonly called "holds".
Short contractions are, however, useful for developing a sense of CONTROL over your PC muscle, in the
same way that piano students do "finger exercise" lessons to better master the keyboard. We now
recommend that you always do a few "flicks" before and after doing your "holds", as a kind of "warm-up"
exercise. You should concentration your exercise efforts on making longer contractions, not just stronger
contractions.
If you cannot sustain a full 10-second "hold", start out at three or four seconds and gradually (over a period
of weeks) increase to the full 10 seconds. Don't worry --- it might take several weeks of regular practice to
get your muscles strong enough to control urinary leakage.
At the end of each twice-daily practice session you should WRITE DOWN your obtained results, in terms
of both duration and strength, so that you can compare your results and reward yourself for progress.
Usually it is advisable to take an numerical average of three or four tries, since it is normal for there to be
some variation between them and you might otherwise be tempted to remember only the "best" one, which
would be less accurate.
You should NOT become excessively tired while doing your Kegel exercises. If you do get tired, it may be
because you are including extraneous muscles --- such as the buttocks, stomach or thighs --- in your
contractions. If you are like most of us, those muscles need exercise too, but this isn't the time to do it.
For one thing, it makes the exercises too exhausting when you are using all those muscles. For another, it
tends to confuse the EMG instrument and give an artificially high reading. (That would be like holding onto
the edge of the sink while using the bathroom scale! Sure it makes the readings better, but you are only
cheating yourself.) And the final reason is that contracting your abdominal wall muscles actually increases
the pressure on your bladder and rectum, and this makes incontinence even more likely. You must learn to
contract only your sphincter (pelvic) muscles to become continent.
As you continue your PC muscle exercise program, you will find that the frequency of urinary
incontinence accidents will probably improve, either dramatically, or gradually. (If it does not, despite
increases in measured muscle strength, you may have other problems and your therapist may recommend
consulting a urologist for an evaluation.)
You should also be aware that, as with any muscle, lack of use will lead to atrophy. Even a few consecutive days without exercise will lead to measurable weakness. When you have completed your formal therapeutic exercise program, and no longer need the electronic biofeedback instrument on a regular basis, you will still need to do regular Kegel exercises. As author Lonnie Barbach says:
"It is quite important to keep this muscle, like others in your body, in tone. The exercises can become as
much of a habit as brushing your teeth, and like brushing your teeth, they should be continued for the rest
of your life."
For Men Only: The Anal Sensor
Although incontinence affects twice as many women as men, there are still some 4 million men in the
United States that have the problem. In addition, as Prostate surgery (for cancer) becomes more and more
common, many men discover that they are glad to be alive -- but very upset that they can no longer control
urinary leakage. For them we have developed an anal version of the Electronic Perineometer™ sensor.
Fortunately, it is just as effective in treating male incontinence as the vaginal sensor is for females -- early
100% effective, without surgery or drugs.
When treating urinary incontinence in females, we make use of the fact that the vaginal canal is very close
to the urethra, so that measurements of urethral muscle activity can be readily obtained through the vaginal
wall. This is much safer than measuring them through the urethral tube itself, since that passage is very
delicate and often gets irritated or infected when instruments must be inserted there. The vagina, on the
other hand, is especially adapted to accommodate foreign objects without becoming irritated or infected.
(It is this ability which makes sexual intercourse relatively safe!) Therefore, whenever possible, urinary
incontinence is treated with a vaginal sensor.
This is one area where women have an advantage over males. But fortunately, the same band of muscles that
encircles the urethra (and the vagina) also encircles the anus, so it is possible to use an anal sensor to train
the pelvic muscles, too.
Unlike the vagina, the anus itself is normally quite dry and it will usually be difficult and uncomfortable to
insert the anal sensor without lubrication. The rounded tip of the sensor can be covered with a small
amount of K-Y™ Jelly, Surgilube, or similar drug-store lubricant just before insertion. It may help to take
a deep breath and push down slightly (as if making a bowel movement) just before pushing it in. As you let
up on the push and the muscle recedes, push the sensor in place. If there is resistance, you can put some
K-Y™ on your finger and lubricate the anus first.
The first few insertions might take a little practice, since it is a perfectly normal and usually a well learned
reflex to contract the anal sphincter muscle whenever you feel anything on the skin there. Once the
rounded retaining bulb on the tip of the sensor passes the muscle, further insertion will be easy. The large
bulb on the "cable" end of the sensor is designed to prevent the sensor from going in too far. When it is up
against the skin on the outside of the sphincter muscle, the electrode pads will be correctly positioned next
to the muscle fibers we are trying to measure.
In all other respects, the directions for biofeedback retraining of the male sphincter muscles are identical
to those for the female.
This page is http://incontinet.com/articles/art_urin/HOPPATIN.htm
Copyright 1996 by John D. Perry
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